For all the cards attendings, fellows out there:
Do you believe it is safe to have a PCI lab in a hospital that does not have CT surgery backup?
Discuss.
i apologize in advance for the length of this post.
1. is the planned intervention for primary PCI (i.e. for acute STEMI/new LBBB) or elective PCI?
2.
the standard of care according to the newly revised AHA/ACC/SCAI guidelines (Dec. 2005).
-elective AND primary PCI to be performed with on-site surgical back-up (class IB).
-primary PCI without on-site surg backup BUT with proven plan for rapid access to cardiac surg OR in nearby facility, WITHIN 1 hour (class IIB).
-primary PCI without on-site surg backup and without a proven plan for emergent transfer w/i 1 hour (class IIIC).
-elective PCI without on-site surgery backup (class IIIC).
the reason there is little rationale for elective procedures without backup is that the procedure is ELECTIVE. there are enough high volume centers in the US with minimal waiting periods that it does not make sense for anyone to not travel a bit to a high volume center with surgical backup. there has been a recent publication in JACC documenting that at Mayo, the need for emergency rescue CABG has decreased over the last 25 years from 3% to 0.3%. even still, for me, 3/1000 chance is higher than acceptable odds for an ELECTIVE procedure. also, your mortality from an emergency rescue bypass is >10%. so if it's gonna happen, you'd want the emergent surgery to be performed at an on-site center with high volume and expertise. there is strong data to show that volumetric criteria in high risk PCI as well as surgery is directly correlated with good outcome.
as for primary PCI, time is myocardium. so naturally, the shorter the door to needle time, the better your morbidity and mortality. so that is why the new ACC/AHA/SCAI recs give primary PCI without backup (but WITH proven emergent transfer plans with door-to-OR times <1 hour) a class IIB recommendation. this could mean life or death for those people in the boondocks, as primary PCi has been proven superior to thrombolysis (we won't discuss the CAPTIM substudy, COMMIT, or CLARITY, alright?).
